Insommnia Flashcards
What is the pathophysiology of insomnia
Hyperarousal in both the central (cortical) and peripheral (autonomic) nervous systems
*may include heightened physiologic, affective or cognitive activity that interferes with natural “disengagement from the environment” and decreases the likelihood of sleep
What are the protective factors
Being male
Being of younger age
Practicing good sleep hygiene (see ‘Non-Pharmacological Measures’ section for explanation of what this includes)
Risk factors
Female
- comorbid conditions: mood disorder, substance use disorder, CV disorder, chonic pain, hormonal changes in preg/menopause, neurologic conditons like epilepsy/parkinsons)
- being of older age
- acute stress or discomfort (death of loved one, acute illness, job loss)
- use od drugs (alcohol, caffeine, cannabis, chonic opiods, sedatives/hypnotics/anxiolytics, stimulants, nicotine)
- use of other pharmacologic agents (adrenergic agonists and antagonists, cholinergic agonsists/ant, chorticosteroids, depamine agonists/ant, hormonal therapy, serotonergic )
Are are common symptoms associated with situational/acute insomnia?
Difficulty sleeping for a few days to a few weeks
Patient may also experience:
-Significant distress
Interference with social, personal and occupational functioning
what does insomnia disorder involve?
dissatisfaction w/ sleep quality or quantity assocaited with at least 1 of:
- difficulty initating sleep, maintianing sleep, early wakenings with inabiltiy to return to sleep
- sleep dsitrubances that cause significant distress or impiarment in impairment in school, work or social settings)
- sleep difficulty occuring despite adequate opportunity for weel
*must occur at least 3 nights/week for at least 3 months to be a clinical dianogsis
*must not be better explained by: another sleep/wake disorder (narcolepsy or parasomnia), physiologic effects of a substance, co existing mental disorder
How are insomnia symptoms classified?
Episodic (present for 1-2 months)
Persistent (present for >3 months)
Recurrent (>2 episodes/year)
what are the potential complications of insomnia
- Psychiatric and medical comorbidities (depression, HTN, diabetes, cardiac events)
- Impaired job performance and higher rates of absenteeism
- More frequent use of healthcare services
- Reduced QoL and more days with limited activity
- More traffic and workplace accidents
for differential diagnosis: what condiitons have similar sings and symptoms
Circadian rhythm sleep-wake disorders; Insomnia only occurs when trying to sleep at socially normal time
Restless leg syndrome: Involves the urge to move legs or other unpleasant leg sensations that disturb sleep
Breathing-related sleep disorders : Patient often has a history of loud snoring, breathing pauses and excessive daytime sleepiness
Narcolepsy : Involves excessive daytime sleepiness, cataplexy, sleep paralysis and sleep-related hallucinations
Parasomnias : Involves unusual behavior during sleep that leads to intermittent awakenings and difficulty resuming sleep
Substance/medication-induced sleep disorder : The substance is the cause of insomnia
for differential diagnosis, what are the distinguishing features of insomnina
- only occurs when trying to sleep at socially normal time
- Involves the urge to move legs or other unpleasant leg sensations that disturb sleep
- has a history of loud snoring, breathing pauses and excessive daytime sleepiness
- Involves excessive daytime sleepiness, cataplexy, sleep paralysis and sleep-related hallucinations
I-nvolves unusual behavior during sleep that leads to intermittent awakenings and difficulty resuming sleep
-The substance is the cause of insomnia
what are the exclusions for insomnia self treatment?
- Symptoms are associated with shift work
- Patient is experiencing:
- An urge to move their legs at night or unpleasant leg sensations
- Snoring, snorting/gasping, or breathing pauses during sleep
- An irrepressible need to sleep during the day
- Sleepwalking, nightmares or sleep terrors
- Symptoms may be drug-related, and the prescriber should be consulted before discontinuation
- No improvement with self-treatment (e.g., drug therapy is ineffective after 3 nights or is required for >7 consecutive nights
What are the goals of therapy for treating insomnia
Promote a sound and satisfying sleep to prevent impaired daytime functioning
Resolve or mitigate underlying conditions that may be contributing to insomnia
Prevent progression to chronic insomnia
Encourage healthy sleep hygiene practices
Discourage excessive use of sedatives by recommending medications only when necessary
Preventative methods for insomnia
*good sleep hygeine
- Personal habits
- Avoid caffeine 4-6 hours before bedtime and minimizing total daily intake
- Avoid nicotine near bedtime
- Avoid alcohol 4-6 hours before bedtime
- Exercise regularly, but not within 2 hours of bedtime
- Avoid heavy, spicy or sugary foods 4-6 hours before bedtime
- The sleeping environment
- Use comfortable bedding
- Ensure the room is a comfortable temperature and well-ventilated
- Block out distracting noises
- Remove light-emitting devices from the bedroom (e.g., televisions, cellphones, computers
- Getting ready for bed
- have light snack (goods high in tryptophan like bananas or containing procyanidin B-2 (tart cherry juice, etc
- use relaxation techniques
- establish pre sleep rituals (few minutes of reading)
best tool to identify behaviours that can be targeting for intervention
keeping a sleep diary
what interventions ahve the strongest evidence for treating insomnia
- Cognitive behavioural therapy
- behavioural therapies (e.g., sleep hygiene, stimulus-control, sleep restriction) + cognitive procedures (e.g., replacing dysfunctional beliefs and attitudes about sleep with more adaptive ones
- First line for acute or chornic insomnia *shown more eff than med
- Stimulus control therapy
- overall goal is to associate bedroom with sleep
- go to bed only when tired, get up at same time each morning, using bedroom only for lseep/intamacy, avoid napping during day, get out of bed only to go to another dimly lit room to read if unable to sleep after 15-20 min
- overall goal is to associate bedroom with sleep
- Relaxation techniques
- can improve sleep latency times
- Progressive muscle relaxation muscle groups are tightened and relaxed one at a time in a specific order
- Biofeedback EEG is used to teach patients how to facilitate increased slow brain wave activity
- can improve sleep latency times
what are interventions that are considered effective for insomnia, but not as strong as the others
sleep restirction: control amount of time spent in bed but increase percentage of time alseep
Paradoxical intention: focuses on removing performance/sleep anxiety by having patient remain awake
*emphasis changes from falling asleep to staying awake so anxiety assocaited with falling asleep disappears
*stronger evidence for CBT< stimulus control therapy, relaxation techniques
